Every day I experience life in the world of healthcare IT, supporting 3000 doctors, 18000 faculty, and 3 million patients. In this blog I record my experiences with infrastructure, applications, policies, management, and governance as well as muse on such topics such as reducing our carbon footprint, standardizing data in healthcare, and living life to its fullest.

Thursday, March 30, 2017

We continue to refine the sanctuary buildings, prepare the new animal care areas, and keep our creatures healthy.

Sweetie, our 18 year old Welsh Pony developed a sore on her right lip. Using my human medicine training I inspected it for abscess formation and drained it, while also applying local antibiotics. It did not heal this week, so we asked the horse vet to take a look. It turns out that when horses have tooth abscesses in the lower jaw, they develop drainage tracts in their lips. Tooth abscesses in the upper jaw drain into the sinuses and out the nose. She’s now on systemic antibiotics and we may pull a tooth next week

My work on the sanctuary's 50 windows and screens, restoring all missing parts, took its toll on my hands. These are supposed to be surgeon’s hands, not filled with cracks and calluses! I guess I’m destined to have farmer’s hands. We had snow, rain, and strong wind this week without a single window/screen issue.

As we go through our checklist of finishing touches on the sanctuary building, we’re fast approaching completion. The last of the replacement carpet, the last of the furniture (library chairs) and the fire alarm system went in this week.

We added bird feeders to support the local fauna, both nut and seed eating types.

We’ve finished the tree work in preparation for the new paddocks as well as trimmed the branches that could injure animals in a windstorm.

As the weather warms, the trail work begins and we’ll walk the property next weekend with leaders from the Sherborn Rural Land Trust, figuring out how to connect existing public property with the sanctuary to create a network of local trails.

We’re hard at work on new paddock designs, ensuring they support a diversity of animals, offer a logical workflow, and abide by all local regulations. In theory, paddock fencing installation should begin in mid-April. Here’s a view of the new areas which maximize animal use of sanctuary land.

This weekend we’ll be training volunteers, rewiring the dining room (that story will be told next week), and hosting a yoga retreat. With good weather planned, we’ll have plenty of animal time, grooming, exercising, and feeding our charges.

Wednesday, March 29, 2017

BIDMC has a long tradition of testing speculative technologies with the notion that breakthroughs often require tolerance for failure. For example, we’ve embraced blockchain in healthcare because we believe public ledgers have promise to unify medical records across institutions.

Over the past few months, we’ve developed healthcare applications for Alexa, Amazon’s ambient listening device that combines natural language processing and easy to use application program interfaces. We have also tried Google Home.

Here’s our experience thus far.

1. We’ve used Alexa in a pilot inpatient setting (not real patients). Here are the questions/use cases we’ve implemented with back end interaction to our operational systems.

Alexa, ask BIDMC
What’s my room number
Who’s on my care team or List my care team
What is my diet or What can I eat
Call a nurse or I need a nurse or Send in a nurse
Give me some inspiration or Inspire me
I need spiritual care or Request spiritual care
I need a social worker or Request social work
What's my care plan for today or What are my planned activities for today
Ok, thanks or Stop or You can stop

2. Sentiment analysis

What is sentiment analysis - the process of computationally identifying and categorizing opinions expressed, especially in order to determine whether the author’s attitude towards a particular topic, product, etc., is positive, negative, or neutral.

We are beginning to use sentiment analysis on social media mentions of BIDMC. We have done a pilot to spot out BIDMC mentions on Twitter and with Google democratizing their sentiment analysis API at the conference a few weeks ago we are working on ingesting the feeds. Conceptually the same approaches can work on Alexa to analyze mood and urgency. We will try it in an attempt to communicate emotion as well as text in the ambient listening workflow.

3. HIPAA Compliance

Alexa and Google Home are not "HIPAA compliant" i.e. neither Amazon nor Google will sign business associate agreements for ambient listening technologies. Both organizations are working on policies and controls that would enable them to sign such agreements for their speech driven products. Once we sign BAAs, we’ll explore use cases like a surgeon asking for patient data without needing a browser/keypad.

In the meantime, we’re not using patient identified data in ambient listening applications. The questions above are anonymous - the HIPAA 18 identifiers (i.e. names, social security numbers, addresses etc.) are not included in the data stream.

We're exploring a few other use cases outside of HIPAA controls, such as querying knowledge bases - commonly asked questions delivered via an ambient listening infrastructure.

4. Accuracy
We have not had any unexpected misunderstandings when parsing spoken language. There is a famous You Tube video illustrating a 3 year asking for hickory dickory dock and getting a pornographic response. The only issue we’ve had is that Alexa can be sensitive to ambient voices, causing it to respond to an unasked question.

5. Expanding the use cases to the outpatient scheduling domain

Amazon has offered Lex as a service that can be used to embed natural language processing in mobile apps that could be used for patient self scheduling. We hope to support a use case of patients in their homes requesting appointment/referrals and interacting entirely with Alexa instead of having to place a phone call or visit a website.

Thus far, we’ve been very impressed with the capabilities of these conversational services. The web was our focus 1996-2012. Mobile has been our focus 2012 to the present, what I call the post-web era. I can imagine that by 2018 we’ll enter the post-mobile era and have conversational interfaces based on ambient listening devices in patient and provider locations.

Thursday, March 23, 2017

It’s officially Spring and although the weather is cold and snowy, the anticipation of warmer weather means that Unity Farm Sanctuary is more active than ever.

This week, a local young woman purchased our goose eggs and made traditional Ukrainian Pysanky Easter eggs. We were impressed.

The owners of Penny Blossom, the Yorkshire pig living at the sanctuary for a year, brought us empty wire cable spools. The goats are jumping from spool to spool, having a great time.

This week, we finished creating the last bedroom at the Sanctuary using a 1760’s bed we found in Plymouth. It was not designed to use a mattress and has spools for ropes to hold straw. Each night you tighten your ropes so you “sleep tight”. That’s actually where the term comes from. Sanctuary guests would likely have trouble maintaining the ropes and straw, so I created a bed frame.

The most important development this week is that we finished clearing the land between the farm and sanctuary in preparation of new animal paddocks for rescue operations. Here’s a view of the freshly cleared land with a herd of deer running across it. In April we’ll install 1700 feet of fencing to create 4 paddocks, each with its own 24 foot mini-barn. We’ve been collecting pottery for a charity sale in the Spring. My daughter joking refers to this area of the property as the “pot farm”.

On the south side of the sanctuary, there are 27 acres of rural land trust open space. We’re creating trails that connect the open space with our land, eventually resulting in 5 miles of walkable trails over the combined land. We hope to expand our bee hives to the meadow in the open space.

I’ve designed paths that follow the natural topography of the land and while exploring the property, I found long abandoned bee hives. My wife asked me to remove them to avoid any potential spread of spores from old American foul brood, but irst I have to talk to the mouse who is renting the old hive!

Over the next few years, we’ll reintegrate the Sherborn land that was originally laid out in the Revolutionary war. If we’re lucky, the assembly of land we own, land trust, wetlands, and farm designated land will result in 200 acres of contiguous agricultural land for the public.

This weekend, we’ll finish the the repair of the sanctuary building, fixing all the windows and screens in the original 1830's building and the newer construction areas. I’ve purchased enough spare parts to restore 50 windows/screens to their original condition. I suspect that by the end of the weekend my hands will be a bit strained!

Wednesday, March 22, 2017

I’ve written several posts over the past two years about the need for innovation in healthcare IT - deploying self-developed apps, leveraging third party cloud hosted functions, and embracing the internet of things.

I’ve previously discussed establishing a center for innovation. In preparation, I’ve worked on innovative projects in industry accelerators, academic collaborations, and government sponsored hack-a-thons.

What has worked?

1. I’ve learned that it is very important to make innovation a part of the day to day work inside an organization. Creating change externally and then trying to graft it internally results in a disconnect between research and operations. At BIDMC, we’ve created a meritocracy in which those have competitively illustrated out of the box thinking are given reserved time each week to focus on highly speculative areas of innovation. The project started as ExploreIT and is now being formalized as the Center for Information Technology Exploration in Health Care.

2. It’s important to leverage commercial tools and services rather than trying to reinvent technologies that are becoming commodities. Agile innovation is the unique combination of existing ideas and is more about creating the plumbing between components to support a workflow than doing large amounts of raw coding.

3. Just as with venture-funded startup companies, in a cohort of 10 projects, 6 will fail, 2 will limp along and 2 will be winners. We must create a safe environment where failure is permitted and exploration is its own reward. We’ll move projects from pilot to production only when they are proven to be ready for prime time

4. We’ll avoid being distracted by magical technologies at the peak of the hype curve (see below). Instead, we’ll choose the appropriate technologies that satisfy business owner requirements based on experience in industries outside of healthcare.

5. At times we’ll be early adopters and will be the first to test a new idea. At other times we’ll be a laggard, allocating our limited resources for the best functionality with appropriate safety and robustness. Also, will not deploy a technology until privacy protection is addressed with appropriate business associate agreements and security controls.

This ExploreIT powerpoint illustrates some of our projects in progress, created by internal staff supplemented with external products and experts selected by our operational teams.

We hope to commit more than $1 million to our innovative efforts this year through a combination of in kind efforts and philanthropy. Thus far, we seem to be achieving a perfect storm of alignment between business owners, internal developers, and technologies to leap frog existing solutions.

Thursday, March 16, 2017

With every passing day, Unity Farm Sanctuary increases its capacity to host public educational sessions, retreats, and events. Our first few months were focused on the historical Unity Hall building. As you’ll see in the photographs below, we’ve made substantial progress. The next few months will be focused on expanding our capacity to give "forever homes" to animals in our community. A design, which works for just about every species we’ll encounter, is done. By May it will be a reality.

Here’s a view of the rooms of the Sanctuary, all assembled from local basements, attics, and donations.

As you enter the original 1833 door, you come upon the meeting room, which is where the weekly meditation group gathers and where we host lectures about diverse topics such as sustainable agriculture, organic farming, and animal care.

The kitchen and surrounding breakfast room is where our volunteers gather for early morning coffee (we have a commercial Bunn coffee machine for an endless pot of organic blends). We will be hosting farm to table events using all Unity Farm products starting this Spring.

The office is where we interview volunteers, have private meetings, and arrange animal placements. The 1760's grandfather clock is still accurate to the second.

The dining room has been restored with its original lighting fixtures, gas lamps converted to electricity.

The library is filled with animal care books and natural artifacts from the surrounding ecosystem.

The bedrooms upstairs are where people stay during our retreats and overnight events. We’ve completed the restoration of 4 rooms thus far.

In the Schoolhouse bedroom, you’ll find a desk from the early 1800s where a local student spilled ink while practicing penmanship on the wood - he/she wrote "Boston, Concord, Eastport (a historical reference to Cape Cod)" in perfect script. The low post bed is a New England country style design found in rural homes during the second half of the 18th Century.

In the French bedroom, you’ll find an 1800’s french bed (which I rebuilt to modern mattress sizing) and a collection of 1700’s horse lithographs

In the Pineapple bedroom, you’ll find a chest owned by an 1800’s Brown University professor and a traditional New England pineapple bed, as well as an 1800’s rocking horse.

Next week, I'll post photographs of the Williamsburg bedroom with it’s 1760’s bed and clawfoot bathtub. We’re restoring the room color paint to an early 1800’s grey-blue.

The loft is a 1000 square foot space with a distressed wood floor looking out over the horse paddocks. The yoga classes, silent retreats, and art events are held here.

By April, our work on the buildings will be done and we’ll focus on the new new animal rescue areas. When we plan a paddock and run in, we pay special attention to manure management, rotation of animals so that the land has a chance to recover, and utilities (electical/water). Here’s a map of that shows the new acre of animal areas between the farmhouse and the sanctuary. We’ve given a great deal of thought to workflow, so that volunteers can easily move animals from paddock to paddock without difficulty. You’ll see that every care area is connected with lanes and gates, so that no volunteer can lose an animal.

Palmer the turkey is really adapting well and he’s a well established member of the community. In a few weeks, we’ll hear about possible donkey and sheep adoption. In the meantime, we continue to support all the creatures of Unity Farm Sanctuary in the cold, wind and snow of the waning 2017 winter.

Thursday, March 9, 2017

When you run a sanctuary, you need to be agile. We received a message that we had until 1pm to rescue a heritage turkey or he would be eaten. We drove the Unity Farm van to pick him up and within 2 hours he was living at Unity Farm Sanctuary. Meet Palmer, a 2 year old Royal Palm turkey He’s social, friendly, and very interactive. He gets along with all the other birds, the dogs, and pigs. I was able to pick him up and move him into the barnyard without a struggle.

Although we now have over 150 birds, we have little experience with turkeys. We let Palmer choose his first roosting spot and he decided to go high - to roost on top of the chicken coop the first night and on top of the goose/duck pen the second night. At this point, he’s very relaxed around all the other birds and spends most of his time with the guinea fowl. You can now hear his “gobble gobble” sound throughout the property as he free ranges over 30 acres.

Although the temperatures have become cold again and snow is falling, the birds are all laying again since the days are growing longer. Here’s what a typical trip to the coop brings - everything from pullet “fairy eggs” (small) to goose eggs (large).

Kathy and I have begun to layout the new pastures and paddocks now that we’ve cleared an additional acre for animals. The sanctuary could potentially house almost anything, so we made a list of all the creatures we may be called on to rescue

so we’ve designed a set of paddocks that can flexibly accommodate all these species, while preserving biosecurity and ensuring everyone gets along.

We’ll begin fence construction the last week of March.

And what’s this about emus? Kathy and I have used the term “elephants and emus allowed” to describe the flexible farming regulations of our town. When I rescued the turkey, here’s who I found living with him.

We’ve heard about 2 emus that may need a new home. Since they run 30 mph and are about as large as a human, keeping them safe and happy could be a challenge.

This weekend we’ll be continuing our work on the new paddocks, preparing for even more snow, and doing some of the last repair work on the sanctuary building - grouting the kitchen counters, repairing broken screens, and rewiring the dining room to install the original lighting fixtures, which were recently donated to the sanctuary by a previous owner. Over the next few weeks, I'll post a virtual tour of what the fully restored sanctuary looks like, room by room.

Thursday, March 2, 2017

In New England we often say that if you do not like the weather, wait 5 minutes. The high this week at Unity Farm Sanctuary was 70F and the low was 5F. We’ve had blankets on the horses overnight then removed them at dawn to prevent overheating. The flowers are blooming now but have frozen solid over cold nights. I fear that our apple crop will be diminished since the young buds will be damaged by killing frosts. There’s not much I can do to battle an unexpected cold snap.

The cold means that every creature - wild and domestic - struggles to stay warm. Turkeys and deer are coming to the barnyard seeking food. Yesterday we woke up to a new “puppy” running through the barnyard. The photos below show the young fox searching for mice and voles in one of the rock walls.

The newest pig at the Sanctuary, Penny Blossom, is a bundle of energy. She really values time with her humans and I’ve been taking her on multi-mile walks every day. She’s very comfortable with her leash and obeys every command. At the end of the walks, she’ll sit in my lap for belly rubs. She’s very comfortable with the other creatures at Unity Farm and wanders around the barn yard on her own (with supervision).

Hazel, our “alpha” pig, is a bit jealous. I’ve made sure she gets her share of belly rubs too.

On the days when the temperature creeps above 50F, the bees have started to gather pollen from emerging skunk cabbage. It’s been a rough winter for bees in New England because of the spread of viruses by varroa mite. We’re expecting 50% losses.

This week we put out a call for volunteers to serve as companions to our animals - offering time to help with their socialization and care. The response has been overwhelming. As we add more creatures, we’ll increasingly depend on volunteers since Kathy and I are limited by the 168 hour week. We only accept animals at the sanctuary when we are confident we can support every aspect of their lifecycle and needs.

This weekend, we’ll be continuing work on the new sanctuary paddocks and animal shelters. Next Friday (if the weather holds) we’ll begin clearing another acre of land. Our design for the new rescue areas will require half a mile of fencing, to be installed in the Spring. With every passing week, the sanctuary grows, providing the infrastructure to support our evolving animal community.

Wednesday, March 1, 2017

At HIMSS, I listened carefully to payers, providers, patients, developers, and researchers. Below is a distillation of what I heard from thousands of stakeholders.

It is not partisan and does not criticize the work of any person in industry, government or academia. It reflects the lessons learned from the past 20 years of healthcare IT implementation and policymaking. Knowing where we are now and where we want to be, here are 10 guiding principles.

1. Stop designing health IT by regulation
Through its certification program, ONC directs the specific features, functionality, and design of electronic health records. As a result, technology developers devote the majority of their development resources to fulfilling government requirements instead of innovating to meet market and clinician demands. The certification program has established a culture of compliance in an industry ready for data-driven innovations. ONC’s role in the health IT industry made sense eight years ago when IT adoption in healthcare lagged considerably behind all other sectors, but today the certification program impedes a functioning market and must be reformed.

2. Align certification with Meaningful Use (MU) and MACRA/MIPS requirements
ONC’s certification program is increasingly disconnected from CMS’s work to streamline pay-for-performance programs. For the first several years of the MU program, certification criteria were tied to MU measures. Though burdensome, certification was directly related to clinicians’ successfully meeting MU requirements. CMS has made progress toward simplifying MU and now the ACI category of MIPS, but unfortunately ONC has not followed suit in the certification program. As a result, the certification program is filled with outdated requirements and is a significant drain on health IT developer resources with no incremental gain to patient care. The certification program needs to be limited to verification of functionality necessary for success in Medicare and Medicaid payment programs.

3. Recognize that information flows best when there is a business case for doing so, not a government mandate
Well-intended government attempts to mandate interoperability have led to unintended consequences that stifle innovation. In every other sector like finance or travel, market dynamics serve as a sufficient driver for information fluidity; policy frequently impedes such a reality in healthcare. ONC should set the conditions for private sector led interoperation efforts—the private sector has and will continue to make tremendous progress to bring seamless information exchange to healthcare. When interoperability is essential to the success of health systems and medical practices, market forces will deliver robust solutions that increase the utility and value of information exchange.

4. Improve access to CMS claims data to drive care coordination
The government does not share its own cost and quality data associated with the millions of taxpayer dollars spent through Medicare and Medicaid. If clinicians had access to the complete claims data for their patients, it would enhance interoperability, driving improvements from increased price transparency for patients to better informed decision-making and communication by clinical teams. There is no legal barrier to CMS sharing its claims data with HIPAA covered entities for the purposes of treatment, payment, and healthcare operations.

5. Eliminate the Enhanced Oversight Rule
ONC’s Enhanced Oversight and Accountability final rule augments ONC’s regulatory authority over health IT products at a time when efforts should be exclusively focused on reducing the burden of the certification program. The rule further increases the administrative burden and cost associated with certification for both health IT developers and government bodies alike. Vendors will have to devote continued attention to proving ongoing compliance with the rule, further limiting the resources that they can devote to responding directly to consumer needs. Program add-ons, such as this increased oversight, will not improve the certification program or the usability of health IT products. Additionally, the authority laid out in the rule is beyond the scope that Congress envisioned when it established a certification program and it paves the way for future overreaches that will inhibit the entire industry.

6. Avoid a heavy-handed approach to patient safety.
Patient Safety Organizations (PSOs, established under the Patient Safety and Quality Improvement Act of 2005) play an important role in improving care quality by providing a space for the healthcare community to confidentially share and learn from patient safety issues. It is essential that ONC leverages this existing framework as it thinks about how to ensure patient safety in health IT, as opposed to a framework centered around government investigation and oversight. A government-led approach has been demonstrated to lead to a “shame and blame” culture where the penalties and government intervention associated with safety issues lead stakeholders to keep issues confidential, rather than ensuring that the entire health IT community can learn from issues experienced by one provider or vendor. Safety is a priority for every health IT vendor. ONC should ensure that it is not unnecessarily inserting itself between vendors and providers when it comes to learning about and swiftly resolving issues.

7. Establish a national patient identifier.
HIPAA called for the creation of a national patient identifier to improve efficiency and safety. While patient-matching technology and processes have improved tremendously since HIPAA was enacted, a national patient identifier would still offer considerable efficiency and safety benefits and would remove a barrier to seamless interoperability.

8. Improve access to CMS data on providers to spur the creation of market-based provider directories.
CMS has the most comprehensive nationwide information on providers in the country. By making this information available as a "shared service" through industry-standard APIs or formats, innovative developers will be able to create a wide variety of value-added applications for providers and patients. The same might also apply to record location leveraging CMS's knowledge of provider-patient relationships. While this information is admittedly more complex due to privacy issues, there are already market-based record location services available through CommonWell and Surescripts that CMS could either supplement or learn from.

9. ONC should focus on "coordination" of government entities.
Federal government provider organizations (DoD, VA, INS, etc) are an important part of the health care delivery in virtually every market of the country. Yet, in most markets these organizations do not participate in the interoperability landscape. These organizations can drive standards-based interoperability not through regulations but through market action. Deploying industry-standard interfaces and APIs and actively participating in "retail" commercial exchange such as CommonWell and Carequality will do more to advance interoperability than any amount of ONC "enhanced oversight".

10. Drive alignment of uniform patient privacy laws across the country.
It's obviously not practical to try to battle each of the 56 states and territories one-by-one, or to try to statutorily enact Federal pre-emption of state privacy laws. However, there are many examples in other industries where the Federal government has motivated alignment of state laws without formally trying to preempt those laws (speed limits, for example). Active participation by Federal agencies in nationwide health information exchanges (#9) that adhere to nationwide HIPAA provisions would be one way to drive this. Tying use of Medicaid funds for local HIE initiatives to alignment with nationwide practices might be another.